Provider Demographics
NPI:1528635455
Name:EAST TENNESSEE CHILDREN'S HOSPITAL ASSOCIATION, INC.
Entity type:Organization
Organization Name:EAST TENNESSEE CHILDREN'S HOSPITAL ASSOCIATION, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT - OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:GODBOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-541-8492
Mailing Address - Street 1:2018 CLINCH AVENUE
Mailing Address - Street 2:OUTPATIENT PHARMACY
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37916-2301
Mailing Address - Country:US
Mailing Address - Phone:865-541-8980
Mailing Address - Fax:865-541-8429
Practice Address - Street 1:2018 CLINCH AVENUE
Practice Address - Street 2:OUTPATIENT PHARMACY
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37916-2301
Practice Address - Country:US
Practice Address - Phone:865-541-8980
Practice Address - Fax:865-541-8429
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EAST TENNESSEE CHILDREN'S HOSPITAL ASSOCIATION, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-06-09
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0004XSuppliersPharmacyCompounding Pharmacy
No3336S0011XSuppliersPharmacySpecialty Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ066560OtherSTATE OF TN DEPARTMENT OF HEALTH